Most countries are not targeting their HIV resources effectively and new strategies must be tried

August 05, 2008

While many national HIV programme managers operate in a fog of uncertainty due to insufficient information on HIV interventions, most are also not using the available data to target their resources effectively. The targeting, selection, and delivery of prevention interventions must be improved, and funding optimised, conclude Stefano Bertozzi, Instituto Nacional de Salud Pública, Morelos, Mexico, and Dr Marie Laga, Institute of Tropical Medicine, Antwerp, Belgium, and colleagues, authors of this fifth paper in The Lancet Series on HIV Prevention.

Epidemic characteristics vary greatly among and within countries, from countries with low levels of spread in all populations like most of the Middle East; to concentrated epidemics where HIV has spread widely in one or more subpopulation, like most of Latin America, Asia, Europe and North America; and finally to catastrophic generalized epidemics where the epidemic has spread widely among the general population as in most of Southern and Eastern Africa. However, the limited data available indicate many countries are not focusing their prevention resources where their epidemics are concentrated. For example, only 34% of countries with a concentrated or low level epidemic in injecting drug users (IDUs) have implemented specific risk prevention strategies. And in countries where the main mode of transmission is among men who have sex with men (MSM) less than 25% of men who have sex with men had access to comprehensive condom-based prevention in 2007. A World Bank assessment of eight African countries revealed intervention combinations bore little relation to the characteristics of the national epidemics. Such discrepancies are not just the province of developing countries. Harm reduction programs for drug users are a cornerstone of development assistance efforts for Australia, yet this intervention receives no support from USA or Sweden, despite it having proven effectiveness.

The authors discuss the difficulties in selecting the right combination of prevention methods for different circumstances, from the slums of South Africa, to MSM in San Francisco to sex workers in Mumbai, India. Proving the effectiveness of such interventions is much more difficult than proving the effectiveness of a drug --because it is harder to measure what doesn't happen (infections prevented). Yet the authors argue that more efforts and creativity should be put in evaluation of prevention programs, than has happened so far- and that the global community has been seriously remiss in not insisting that such evaluations be built into prevention programs as they scale up.

Even when prevention programs do a good job selecting the right interventions and targeting them to the appropriate populations, the program can fail if its delivery is not well managed. Lessons must be learned from sites that provide prevention services in the most efficient way, managerial capacity must be strengthened, and the cost and quality of services must be continuously measured and assessed at the facility level. Donors should condition funding on the basis of results and performance.

Finally, the authors address the question "How much money does a country need for HIV prevention?" The answer clearly depends on how much it costs to prevent an infection - which depends on how well a country chooses its interventions, targets is program and delivers services efficiently. However, countries everywhere are under-investing in prevention. A previous study has suggested that interventions that cost $4770 per infection prevented would not only be cost effective they would save money because of all the savings in treatment costs. Yet, coverage remains extremely low even for interventions that cost $1000 or less per infection prevented, eg, antiretroviral treatment to stop mother-to-baby transmission. And some global donors are more generous than others -- Norway donates four times the amount to HIV/AIDS than Italy, despite having an economy one sixth the size. And some developing nations receive a lot more than other relative to need - the authors suggest that funds should be dispersed more fairly, based on their relative needs.

The authors conclude: "The past 25 years of HIV prevention have been characterised by islands of success in a sea of failure. Millions of people would not be newly infected each year if that were not the case....although we still hope that a magic bullet will one day be discovered, we must now start designing and implementing prevention programmes that can succeed without one...Scaling up prevention efforts with known effectiveness, such as harm reduction and sex work interventions, remains an urgent public-health priority. Furthermore, taking the risk of rolling out large-scale programmes of combination prevention, despite their uncertain effectiveness, is the only way we can understand their effects and learn how to improve them."
Dr Stefano Bertozzi, Instituto Nacional de Salud Pública, Morelos, Mexico T) +52-777-329-3069 E);

Dr Marie Laga, Institute of Tropical Medicine, Antwerp, Belgium T) +323-247-6316 E)

Please note: a press conference to launch this series will take place at the International AIDS conference on Tuesday 5 August, 1500-1545 (Mexico City time) in Room 1 (Aztecas), Media Centre, Hall A, Level 1, Centro Banamex, Mexico City


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